Safe percutaneous dilational tracheostomy in 5 patients with ARDS by Covid-19

To the Editor:

Coronavirus disease 2019 (Covid-19), caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2), is a disease with a clinical spectrum that ranges from asymptomatic to critical disease requiring Intensive Care Unit (ICU) admission, intubation, and prolonged mechanical ventilation due to a severe acute respiratory distress syndrome (ARDS) [1]. Despite the large and growing number of cases of Covid-19 disease around the world, there are few publications related to the performance of tracheostomies in Covid-19 patients who require prolonged mechanical ventilation. We describe our experience in 5 patients with laboratory-confirmed COVID-19 admitted in the ICU of Clinical Hospital of Santiago de Compostela who underwent elective bedside percutaneous dilational tracheostomies (PDT) during April 2020. This prospective case series was approved by the Research Ethics Committee of the Galicia, Spain, number 2020-188. Informed consent for the procedure was provided by all patients or a close relative of the patient. All patients were admitted with severe ARDS. Patient demographics, comorbidities, clinical ICU course and treatments are described in Table 1 . Tracheostomy was performed after a mean of 16 (13-27) days of invasive mechanical ventilation and the patients presented a PaO2/FiO2 ratio of 167 (92-206). PTD took place in ICU, in a closed room. Team that performed PTD consisted of 3 anesthesiologists and a circulation nurse. One anesthesiologist managed airway and bronchoscopy, and the other two performed the PTD. Each person wore standard personal protective equipment PPE (FFP3 mask, surgical cap, goggles, surgical gown, and double gloves). During procedure, all patients were deep sedated and paralyzed. During tracheal puncture mechanical ventilation was stopped and we used a Single-Step dilatation technique (Ciaglia Blue Rhino G2 Advanced Percutaneous Tracheostomy Kit (Cook Medical)) with the help of a bronchoscope to control the puncture site, the direction of guidewire, and the location of tracheostomy. PTD was performed at the bedside in all five patients without difficulty, and no complications were found. Neither the nurse nor the anesthetists who participated in the PTD developed symptoms or tested positive for Covid-19 fourteen days after procedure.

Table 1.

Clinical Characteristics patients with severe ARDS by COVID-19 where tracheostomy was performed.

	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5
Characteristics
Age, yr	68	70	70	63	68
Sex,	F	M	M	M	M
Weight, kg	65	92	75	90	97
Height, cm	165	165	162	176	166
APACHE II score	21	17	21	16	20
PaO2/FiO2 in ICU admission (mmHg)	180	206	92	133	173
PaO2 in ICU admission (mmHg)	80	124	92	106	104
Chronic medical illness
Hypertension	No	Yes	Yes	No	Yes
Diabetes	No	No	No	No	Yes
Chronic obstructive pulmonary disease	Yes	No	No	No	No
Heart disease	No	Yes	Si	No	Yes
Laboratory parameters
Leukocytes count per mL	17980	8400	4800	3450	7400
Lymphocytes count per mL	230	510	180	280	1080
C-reactive protein, mg/L	25	15	5	7	17
D-dimer, ng/mL	4870	707	1900	357	1295
Lactate dehydrogenase, U/L	989	600	248	519	913
Creatine kinase, ng/mL	291	140	33	110	54
Serum Ferritin, μg/L	531	2650	689	2898	653
Interleukin-6, pg/mL	158	85	1819	670	77
Procalcitonin, ng/mL	13,3	0,32	64	0,46	0,22
Triglycerides, mg/dL	127	195	118	256	117
Treatment
Hydroxychloroquine	Yes	Yes	Yes	Yes	Yes
Lopinavir/ritonavir	Yes	Yes	Yes	Yes	Yes
Azithromycin	Yes	Yes	Yes	Yes	Yes
Tocilizumab	No	No	Yes	No	Yes
Glucocorticoids	Yes	Yes	Yes	Yes	Yes
Clinical ICU course
Duration since intubation to tracheostomy (days)	13	27	17	16	16
Length of ICU stay (days)	39	31	38	40	39a
Survival at 21 after PTD	Yes	Yes	No	No	Yes

^aRemained ICU, PTD: percutaneous dilational tracheostomies.

PTD is a common, minimally invasive procedure to facilitate tracheostomy placement, and it represents an alternative to traditional open tracheostomy. We prefer to perform PTD because it is fast, safe, and with low complications. It is performed in our ICU at bedside, avoiding transport of Covid-19 patients to the operating room with repeated connection and disconnection of ventilatory circuits during transfer. Although open tracheostomies were favored over PTD during the SARS outbreak [2], techniques for PTD have advanced since then. We used a single stage “Rhino” dilator technique avoiding multiple entries. Procedure was performed under deep sedation and full neuromuscular blockade to prevent coughing, and we stopped mechanical ventilation just before performing the PTD, to minimize aerosol generation. Although the use of the bronchoscope could generate an increase in aerosols, we believe that it is worth using it due to the increased safety for the patient when performing the procedure. During the procedure we paid meticulous attention to the details of infection control, to minimize cross-contamination and our risk of contracting the illness [3,4].

The optimal timing of tracheostomy in ventilated Covid-19 patients remains controversial. We perform our PTD 14 days after endotracheal intubation (IOT) as recommends the American of Otolaryngology-Head and Neck surgery [5].

In conclusion, there is no evidence whether PTD or surgical open tracheotomy is less aerosol generating. We considered that PTD may be a safe and effective technique for COVID-19 patients with ARDS. Future studies will determine the role of percutaneous tracheostomy in Covid-19 patients with difficult disconnection from mechanical ventilation.

Clinical trial number: Code No. 2020-188.

Prior presentations

No.

Funding statement

No funding provided.

Support

Support was provided solely from institutional and departmental sources.

Authors contributions

• 1.Conception of the study: Manuel Taboada, Valentin Caruezo
• 2.Study design: Manuel Taboada,
• 3.Data collection: Manuel Taboada, Agustín Cariñena, Francisco Aneiros, Albero Naveira, Pablo Otero.
• 4.Data analysis: Manuel Taboada
• 5.Drafting the manuscript: All authors helped to revise the draft of the manuscript
• 6.Editing and approval of the manuscript: All authors

Declaration of competing interest

The authors declare the absence of conflict of interests.